23 WOODSIDE ST - BUILDING INSPECTION (2) A
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the Commonwealth of Massachusetts
Dy Board of Building Regulations and Standard RECEIVE
Massachusetts State Building Code, 780 CMINSPEET(ONAL OF ERVE
Revised Mar 2011
Building Permit Application 'ro Construct, Repair, Renovate ChWMlis�tq 2 1 b
One-or Two-Family Dwelling `tl
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) z)
Signature Date
SECTION I:SITE INFORMATION
A Property Address: 1.2 Assessors Map& Parcel Numbers
3 571 _
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 'Zoning Information: IA Property Dimensions:
zoning Distrfcl Proposed Use [.,or Area(sq ft) Frontage(11)
1.5 Building Setbacks(I'D
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (,�LGI.c. 10,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Reco�:
C�}t2L A2 G`S As) _ s/f LC�iM . /yli9 O/lam 7�
Nmne(Print) Ci(y,Stale,ZIP
2— impsipe- 57-1 P6 526S3N Cm�v��c,� a Ile-IB&.4
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Spccily:_ _
Brief Descriptir raysNet'
SECTION 4: ESThM,%,rED CONSTRUCTION COSTS
her Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Itern 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical 0-ire
Suppression) S Total All Fees:
XCheck No.----Check Amount__Cash r\mount:_
6. Total Project Cost: $ f? V ❑ paid in Full ❑Outstanding Balance Due:
64�zb -ram
s"lNd 1 -?�`-1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Down,State,ZIP M Mason
ry
MD
RoofingCovering
Window and Siding
Solid Fuel Burning Appliances
Insulation
'1'ele hone Email address Demolition
5.2 Registered Home Improvement Contractor(IIIC)
HIC Registration Number Expiration Date
HIC Company Name or f11C Registrant Name
No.and Street
Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject properly,hereby authorize
to act on my behalf, in ail matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
C� 12L &tn 4/S.4yo 7 /?Z i
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.niass.Lov/dps
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. If) Habitable room count
Number of fireplaces______ Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cool in.system_ Enclosed Open —
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
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CITY OF [, 1%C-1S&kCHUSETTS
BLILDLNG DEAR-ME`-r
,,die Y hr 130 TASHLYGTON S-MEET 3w FtOOR
T�L (973) 745-9595
KIMBERLEY DRlSCOLL FAA(978) 7-W-994S
NLAYOa
T�-IOJL�3 ST.Pl�gttg
DIRECTOR OF PLOLIC PROPERTy/H(:ILDLNG CO-NWISSfO,NEZ
Construction Debris Disposal AFtidayit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 U411 section
Dcbris, and tite provisions of IMGL c 40, S j4; 111.5
Building Permit M
is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by ,�IGL e
l 11, S I50A.
The debris will be transported by:
y
y
(name ut'haulur)
The dQhris will be disposed uF in ;
—_----(iJdressortaeility)
41re
ut'prrrnit,,pp(iu�nt
CITY OF SALEM, MASSAC HUSETTS
BUILDING DEPARTMENT
120 WASBNGTON STREET,3RD FLOOR
�nnsnx�' TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR M40MAS STTIERRE
DIRECCOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date / 20/�
Job Location 23 WgOM/De� 57-'
Home Owner Address-Z3 "00DS//P6E 5
Present Mailing Address 7Z-3 000DSIPC ST
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR